1. Prescription Writing Basics
Medication errors occur at a rate of approximately 20%
1.3 million people are injured and approximately 7000 deaths occur each year in the U.S. from medication-related errors
Drug-related morbidity and mortality is estimated to cost $177 billion in the U.S.
Gordon 5/2014

2. Objectives Discuss the different types and classes of medications
Discuss the importance of properly written prescriptions
Provide an overview of medication errors
Review the proper format for completing prescriptions
Practice calculating drug doses
Provide an overview of electronic prescriptions

3. Types of Medication Regular
Viewed as non addictive or not habit forming
Controlled
Potential to create psychological or physical dependence
Over the counter (OTC)
Available without a prescription

4. Regular Medications Must be prescribed by a licensed provider
Available only with a prescription
Limited quantities up to 1 year(includes refills)
Requires a completed prescription
Hand-written, call-in, or e-script
NPs may prescribe medications in 49 states (with and without limitations)
Several states have specific formulary requirements

5. Controlled Substances
Referred to as “scheduled drugs’
Schedules I-V
Requires a DEA number and provider licensure to prescribe
12 states and the District of Columbia allow NPs to prescribe controlled substances independently
28 states require physician collaboration for prescribing controlled substance
10 mention physician supervision in their guidelines

6. Controlled Substance Schedule I Schedule II High potential for abuse
Very likely to cause psychological and physical dependence
These medications have no acceptable use in the United States
Heroin, LSD, marijuana, ecstasy, methaqualone, and peyote
Less risk for dependency than Schedule I
Less likely to be abused than Schedule I drugs
Cocaine, methadone, Dilaudid, Demerol, oxycodone, Fentanyl, Dexedrine, Adderall, etc.
1 month supply- no refills
All hydrocodone products moving to this class Oct

7. Controlled Substance Schedule III Schedule IV
Lower potential for abuse than Schedules I and II
Codeine- up to 90 mg per dose; testosterone, ketamine, anabolic steroids, suboxone, etc.
For now *** Includes less than 15 mg of hydrocodone products in combination with other products such as acetaminophen (change 10/2014 to C-II)
Low potential for abuse and or dependency Xanax, Valium, Talwin, Ambien, Ativan,Klonopin, Restoril, Ultram etc.
Schedule III-IV drugs may have up to five refills allowed (6 month supply)
May be given as a verbal prescription to the pharmacist

8. Controlled Substance Schedule V Lowest risk for abuse and dependency
Generally anti-diarrheal, antitussives, and pain management
Includes Lomotil, Lyrica, Robitussin AC
No limit on refills in a year period
However, monitor the number you are prescribing
May be faxed to pharmacy
Valid for 12 months from issue date

9. OTC Medication May be written on a prescription
Can serve as a written reminder for the patient
May be covered by Health Savings Accounts
Medicaid has covered some OTC meds in the past
May be cheaper for generic versus OTC
Prilosec OTC versus omeprazole

10. Writing Prescriptions Correctly
Prevent patient injury or harm
Decrease costs of healthcare
Diminish risk of disciplinary action, license suspension, or revocation

11. Medication Errors What is an adverse drug EVENT?
Harm or injury to a patient as a result of medication
Can be drug reaction
Even properly prescribed, allergic reactions may occur
May be the result of improperly written prescription (OCS Errors)
Error of omission
Error of commission
System error

12. OCS Errors Omission Failing to do something Commission
Doing something WRONG
System
Not due to prescriber’s efforts
Drug name look a-likes and mix ups
Patient information- weight, pregnancy, etc.
Medication delivery device
Patient education

13. Most Common Errors Indication errors
Under use or over use of medications
Dosing Errors
Trailing zeroes, illegible writing
Drug-Drug interactions
Not reviewing current medications
Inadequate Records
Lack of full disclosure of current medications
Misread or misinterpreted prescriptions

14. Avoiding Errors: The 5 Rights
Right patient
Right drug
Right dose
Right time
Right route

15. Avoiding Errors: Abbreviations
Do Not Use…
Write Instead…
U, u IU
Q.D., QD, q.d., qd,
Q.O.D., QOD, q.o.d., qod
Trailing zero (X.0); lack of leading zero (.X)
MS, MS04 and MgS04
Write “unit”
Written International Unit
Write “daily”
Write “every other day”
Write “X mg” or write “0.Xmg”
Write “morphine sulfate” or “magnesium sulfate”

16. Components of a Hand-written Prescription
Prescriber’s Full Name and Address
Telephone number, license number, DEA number
Date Prescription is Written
Patient’s full name and address and/or D.O.B.
Legible Prescriber signature
Drug name, dose, dosage form, amount
Directions for use, indication
Refill instructions

17. Prescription Pad Requirements
All of the following items must be present in a prescription pad to be compliant with the “tamper resistant “ guidelines set forth by Centers for Medicare/Medicaid (CMS):
One or more features to prevent unauthorized copying
One or more features to prevent erasure or modification of information as written by the prescriber on the prescription
One or more features to prevent the use of counterfeit prescription forms

18. Examples of Tamper Resistant Changes
Background color should be blue or green with a design that is hard to reproduce
The paper should have an artificial watermark- this makes it difficult to erase or alter ink
The words "void" or "illegal" must appear when the paper is photocopied.
Heat sensors and watermarks that appear when the script is copied are options

19. Prescription “Void Appears When Copied”

20. E-Prescribing Same information collected from patient
Name, DOB, weight, current meds, allergies, medical diagnoses, address, phone number, pharmacy of choice as well as health care coverage/insurer
Stored in electronic health record
Can be generated at office visit or for refills
Pharmacy receives prescription and processes for fulfillment

21. Points to Remember Limit each prescription to one medication
Circle your name when using preprinted prescription pads
Approach medication names with caution
Eliminate confusing abbreviations
Use metric measures for dosages
Avoid writing “as directed”
Specify the therapeutic duration
Prescribe specific quantities rather than dispensing for time periods

22. Points to Remember Remain cognizant of lethal doses of medications.
Choose dispense as written (DAW) if necessary
Double check your dosage
Quantity of pills to be dispensed (Avoid writing “Quantity Sufficient”)
Include the correct date
Include the correct route (by mouth, per rectum, etc)
Your signature
Mark your refills

23. Student Nurse Practitioners
As a student Nurse Practitioner, you are NOT permitted to prescribe medications
You cannot keep prescriptions that are signed by your preceptor and fill them out
You cannot be solely responsible for the plan of care

24. Prescription Writing Practice

25. Drug Calculations Weight and age of patient
Convert pounds to kilograms: 2.2 pounds = 1 kg
Weight in pounds ÷ 2.2 = weight in kg
Concentration of oral suspension
Ex:400mg/ 5 ml
400mg/5ml=80mg/1ml

26. Example 1
Jane Smith has hypertension and needs a prescription for Vasotec. She will take 5 mg, twice a day. It comes in 5 mg tablets. She will need a three month supply with refills for a year. Her address is 330 East First Street, Duluth, MN
Prescription:
Vasotec 5mg tablets
Sig: 1 tab po BID disp #180 RF:3

27. Example 2
John Smith needs a prescription for eye drops. He uses one drop of Timoptic 0.5% in his right eye twice a day. It comes in 5 cc bottles. He needs three refills. Mr. Smith’s D.O.B. is 2/13/70.
Timoptic 0.5% eye drops
Sig: 1 gtt to right eye BID Disp: One 5 ml bottle RF: Three

28. Example 3
Jane Smith’s 12 year-old daughter Emily has asthma. She needs a three week course of tapering dose of Prednisone. She needs 40 mg per day for one week, then 20 mg per day for one week, then 10 mg per day for one week. It comes in 10 mg tablets. She should get no refills. She weighs 97 pounds and D.O.B. is 4/26/2002.
RX:
Prednisone 10 mg tablets
Sig: take four 10 mg tab po daily x 7 days then
take two 10 mg tab po daily x 7 days then
take one 10 mg tab po daily x 7 days.
Disp 52 tablets. RF: 0

29. Example 4
John Smith has a broken arm and needs Norco for pain. It comes in 7.5 mg tablets. He should take one tablet every four hours as needed for pain. He needs thirty pills. No refills. His address is 4400 W. Grand Ave, Duluth, MN
RX:
Norco 7.5 mg tablets
Sig: take 1 tablet po every 4 hours as needed for arm pain
Disp #30 (thirty) tabs NO refills.
** write out the amount of pills for any pain medication to prevent tampering

30. Example 5
John Smith’s 2 month-old son Jimmy is diagnosed with otitis media. You want to prescribe Amoxil by mouth every 12 hours for 10 days. Amoxil suspension is available as 125mg/5mL. Jimmy weighs 12 pounds.  The safe dose is 30mg/kg per day. Jimmy’s D.O.B. is 04/24/2014.
Note that this example is a liquid medication. This is common in pediatrics but you will find you have adults who cannot swallow pills.
As you can see the provider in this case has chosen Amoxil 125mg/5 ml. There are different concentrations available.
The dosage is based on age and weight.
12/2.2= 5.5 kg – change from lbs to kg
Here is the math:
30mg x 5.5kg= 165mg/day divided in 2 doses = 82.5mg per dose
125mg/5mL ( suspension available) x 82.5mg/ ?mL= 3.3mL per dose
6.6 mL per day x 10 days= Dispense 66mL quantity
So RX is:
Amoxil 125mg/ml
Sig: 3.3 ml po BID x 10 days Disp 66 ml RF: 0